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VADM Willard P. Arentzen, MC, 

Surgeon General of the Navy 


RADM R.G.W. Williams, Jr., MC, USN 

Deputy Surgeon General 


Sylvia W. Shaffer 


June Wyman 


Virginia M. Novinski 

Nancy R. Keesee 


Contributing Editor- in-Chief: 
CDR C.T. Cloutier (MC) 
Aerospace Medicine: CAPT M.G. Webb 
(MC); Dental Corps: CAPT R.D. Ulrey (DC); 
Education: CAPT J.S. Cassells (MC); Fleet 
Support: LCDR J.D. Schweitzer (MSC); 
Gastroenterology: CAPT D.O. Caste!] 
(MC); Hospital Corps: HMCM H.A. 
Olszafc; Legal: LCDR R.E. Broach 
(JAGC); Marine Corps: CAPT D.R. Hauler 
(MC); Medical Service Corps: LCDR J.T. 
Dalton (MSC); Naval Reserve: CAPT J.N. 
Rizzi (MC, USN); Nephrology: CDR J.D. 
Wallin (MC); Nurse Corps: CAPT P.J. 
Elsass (NC); Occupational Medicine: CAPT 
G.M. Lawton (MC); Preventive Medicine: 
CAPT D.F. Hoeffler (MC); Psychiatry: 
CAPT R.W. Steyn (MC); Research: CAPT 
C.E. Brodine (MC); Submarine Medicine: 
CAPT H.E. Glick (MC) 

POLICY: U.S. Navy Medicine is an official publication 
of the Navy Medical Department, published by the Bureau 
of Medicine and Surgery, It disseminates to Navy Medical 
Department personnel official and professional information 
relative to medicine, dentistry, and the allied health sci- 
ences. Opinions expressed are those of the authors and do 
not necessarily represent the official position of the Depart- 
ment of the Navy, the Bureau of Medicine and Surgery, or 
any other governmental department or agency Trade 
names are used for identification only and do not represent 
an endorsement by the Department of the Navy or the Bu- 
reau of Medicine and Surgery. Although U.S. Navy Medi- 
cine may cite or extract from directives, official authority for 
action should be obtained from the cited reference. 

DISTRIBUTION: US. Navy Medicine is distributed to 
active-duty Medical Department personnel via the Standard 
Navy Distribution List. The following distribution is author- 
ized: one copy for each Medical, Dental, Medical Service 
and Nurse Corps officer; one copy for every 10 enlisted 
Medical Department members. Requests to increase or de- 
crease the number of allotted copies should be forwarded to 
U.S. Navy Medicine via the local command. 

CORRESPONDENCE: All correspondence shoujd be 
addressed to: Editor, US. Navy Medicine, Department of 
the Navy, Bureau of Medicine and Surgery (Code 0010), 
Washington, D.C. 20372- Telephone: {Area Code 202) 
254*4253, 254-4316, 254-4214; Autovon 294-4253, 294-4316, 
294-4214. Contributions from the field are welcome and will 
be published as space permits, subject to editing and pos- 
sible abridgment. 

The issuance of this publication is approved in accor- 
dance with Department of the Navy Publications and 
Printing Regulations [NAVEAOS P-3S). 


Volume 68, Number 9 
September 1977 

T From the Surgeon General 

2 Department Rounds 

HMC Joseph Laskowski is Sailor of the Year ... A look at NRMC 
Yokosuka Alcohol Rehabilitation Unit . . . Not for flight surgeons 
only . . . Tanker evacuees get emergency care 

7 Features 

Patient Education; A Tool for Efficient Health Care Delivery 
LCDR R. Downs, NC, USN 
LCDR P. Eklund, MSC, USN 
LCDR R. Shaver, MSC, USN 

12 Navy Diving Biomedical Research and Development: 
The NMRI Program 
M.M. Matzen 

17 NAVMED Newsmakers 

18 Soundings 

War on Shipboard Roaches 
LCDR R. V. Peterson, MSC, USN 


20 On Duty 

Solid Shield 77 

23 Policy Instructions and directives 

24 Notes and Announcements 

In Memoriam: CAPT B.F. Avery, MC, USN . . . Captain selectees 
for FY78 . . . Dental continuing education courses . . . AFIP train- 
ing announced . . . AMSUS to hold annual meeting . . . Deadline 
for USUHS applicants . . . Abstracts sought for pediatric seminar 
. . . Health care administration class graduates . . . "Go Navy" 

26 Professional 

A Questionnaire for Preventive Dentistry Programs 
CDR L.W. Blank, DC, USN 

COVER: This hard-hat diving system was evaluated at the Naval Medical 
Research Institute in the early 1970's to determine the impact of diving 
equipment and systems on a diver's safety and performance. For a re- 
port of the NMRI diving biomedical research and development program, 
see page 12. 


From the Surgeon General 

Now the 

THE SITUATION we have all lived 
through this summer reminds me of 
this story: 

A general serving under Fred- 
erick the Great was promised a 
force of 60,000 men. But on review- 
ing his troops he found only 50,000. 
When he protested, Frederick the 
Great replied, "There's no mistake. 
I counted you for 10,000 men." 

Frederick and his general would 
feel right at home in today's Medi- 
cal Department where we have sur- 
vived a long summer of shortages in 
manpower and money. All Medical 
Department members have been 
called upon to perform well beyond 
normal expectations— to compen- 
sate for a shortage of physicians by 
counting themselves and perform- 
ing as more than one. 

It is time to recognize the many 
benefits resulting from your "above 
and beyond" efforts. 

Some good things are happening. 
Recruiting is improving at the same 
time our scholarship programs are 
starting to pay off. This year we 
selected 284 new students, and we 
have asked for funds to increase 
that number by 111 next year. 

In the FY79 budget, the Chief of 
Naval Operations has identified 
nearly 20 million additional dollars 
for Medical Department programs. 
As a result we not only have recent- 
ly installed our first computerized 
axial tomography scanner at NRMC 
San Diego, but have also gotten 
approval for two more CAT scan- 
ners for NRMC Portsmouth and the 
National Naval Medical Center in 

Our construction programs- 
bogged down for a white— now 
show signs of getting back on track. 


VADM W.P. Arentzen meets with USS 
Orion hospital corpsmen (from left: 
HM2 H.R. Keesing, HM3 H.J. Harden 
and HN D.A. Stamour) 

Ground has been broken on the new 
hospital at Orlando. Plans are going 
forward for the new hospital at 
Yokosuka, and we have reached 
agreement with the city of San 
Diego to locate our new medical 
center there in Balboa Park, close to 
the fleet the facility serves. 

We are actively planning to rein- 
state the Physician's Assistant Pro- 
gram in FY79. Our PAs have done a 
splendid job for us; we need more of 

The bill to extend Variable Incen- 
tive Pay and Continuation Pay for 
medical and dental officers for 
another year has cleared the House 
and should go to the Senate floor 

In the Nurse Corps, we are still 
able to recruit enough officers to 
remain at full strength. The total 
number of Nurse Corps billets is 
less than we need, but we are look- 
ing into ways to get the authorized 
strength increased. 

A Patient Education Task Force, 
under the auspices of the Naval 
Health Sciences Education and 
Training Command, has begun to 
develop plans for a comprehensive 
patient education program to guar- 
antee that all Navy health care 
beneficiaries receive the informa- 
tion they need to maintain good 

Next year we will offer 14 more 
GME-1 positions to help accom- 
modate more of our scholarship 
students. I keep a close watch on 
our training programs and am 
totally committed to top quality 
training. If a program can't be kept 
top-notch and viable, it will be 
closed. There is no question that we 
will have to train the bulk of our 
future specialists ourselves; tradi- 
tionally, the physicians we train 
have been the physicians we retain. 

I commend you for the under- 
standing and resourcefulness you 
have shown in what have been by 
any measure most trying times. 
Your performance proves again that 
the Navy can count on the men and 
women who make up its health care 



Vice Admiral, Medical Corps 

United States Navy 

Volume 68, September 1977 



"Sailor of the Year," HMC Joseph B. Laskowski . . . 

Department Rounds 

Sailor of the Year 

Honors for the Navy's Best 

"It's like a man walking in a field 
during a thunderstorm and a light- 
ning bolt hits him. He's not expect- 
ing it at all," says HMC Joseph B. 
"Doc" Laskowski, describing how it 
feels to be named Atlantic Fleet 
Sailor of the Year. 

The 28-year-old hospital corps- 
man officially received this title and 
promotion to chief petty officer 
during a formal ceremony at the 
Pentagon on 25 July. Participating 
in the ceremony were Secretary of 
the Navy W. Graham Claytor, Jr. 
and Chief of Naval Operations 
ADM James J, Holloway III. Later 
Chief Laskowski received congratu 
lations from top Medical Depart 
ment officials on a visit to the 
Surgeon General's office. 

"The title Sailor of the Year is 
given annually to three people — 
one enlisted man or woman from 
the Atlantic and Pacific Fleets and 
one from combined shore activi- 
ties," Chief Laskowski explains. 
"The honor recognizes the very 
best all-around Navy member, with 
emphasis on professionalism." 

Chief Laskowski was nominated 
for the award while serving as a 
hospital corpsman first class aboard 
the minesweeper USS Detector. His 
commanding officer, LCDR D.B. 
Quelch, wrote in the nominating 
letter: "Petty Officer Laskowski has 
in one year provided the crew with 
one of the finest medical depart- 
ments to be found on any mine- 
sweeper." Laskowski was also 

praised for his involvement in the 
ship's education program and for 
his extensive work in many com- 
munity action projects. 

Community action. The young 
Navyman believes his involvement 
in civilian projects, as well as his 
professionalism, helped him secure 
the high honor. "It was especially 
through my drug abuse education 
classes that I came into close con- 
tact with the community," he says. 

"I associated myself with the var- 
ious community action groups and 
offered my services as a lecturer in 
pharmacy. One thing led to another. 
I would give lectures for area PTA 
meetings, church and civic groups, 
and police departments. I affiliated 
myself with the Mental Health and 
Mental Retardation Board in Ports- 
mouth [Va.], and the city sent me to 
the University of Miami to learn 
how to set up a community aware- 
ness team." 

U.S. Navy Medicine 

The six-foot, mustachioed Las- 
kowski, as a youngster, moved 
"about 10 times" with his family 
before graduating from Mentor 
(Ohio) High School in 1968. Then he 
headed straight for the Navy re- 
cruiting office. He completed basic 
training that same summer and in 
August, newly married, was sent 
to Camp Pendleton, Calif. There he 
attended Field Services Medical 
School, preparing for more than two 
years' duty with Marine Corps units 
in Vietnam, Okinawa, Taiwan, Ja- 
pan and Korea. 

Instructor. When he returned 
home, "Doc" Laskowski once again 
became a student, this time at the 
Portsmouth, Va., Medical Service 
Technician School. During that 
training he developed his interest in 
pharmacology and drug abuse prob- 
lems. He was selected to stay on at 
Portsmouth as an instructor in phar- 


. . . relaxes with family 

macology, pharmacy math, and 
drug abuse education. 

But he realized that to be truly 
effective he would have to broaden 
his educational background, so 
Laskowski enrolled in an off-duty 
study program sponsored by George 
Washington University. In 1975, he 
earned an associate degree in 

From Portsmouth, Laskowski, 
who wears nine military decora- 
tions, joined the minesweeper De- 
tector, and went on to win the 
coveted title Sailor of the Year. 

"There are intangible benefits to 
being the Sailor of the Year," Chief 
Laskowski says, "such as the recog- 
nition that all hospital corpsmen will 

be receiving through me, and the 
personal satisfaction of being able 
to represent the entire enlisted com- 

With pride and a broad smile, 
Laskowski goes on to say, "When 
we Sailors of the Year accept the 
award it's not just for ourselves and 
our families, but for all the enlisted 
people — and there are many who 
are outstanding." 

Following the ceremony in Wash- 
ington, the Laskowski family, in- 
cluding daughter Carol, 8, and son 
Joseph, 5, flew to San Diego for a 
five-day all-expense-paid vacation. 

Awaiting the Sailor of the Year on 
his return to Norfolk was a new job 
as assistant to the Atlantic Fleet 
Master Chief Petty Officer. Chief 
Laskowski will work with the fleet's 
rop-ranked enlisted man to identify 
potential problem areas in the wel- 
fare and morale of Atlantic Fleet 
personnel and their dependents. 

"Part of my job will be to visit 
fleet units and talk to people to get 
the pulse of what's going on," he 

And Chief Hospital Corpsman 
Joseph Laskowski, Sailor of the 
Year, should have no trouble find- 
ing that pulse. 

— Story by Pat Thiele. Photos by Archie 
Galloway and Milt Putnam. 

Volume 68, September 1977 

Inside the Alcohol Rehabilitation Unit 

Some lumber into the hospital 
conference room with relaxed 
strides; some are sullen, hesitant, 
or passively blank; still others sit 
with good-humored grins wreathed 
in cigarette smoke. 

They wear Navy and Marine 
Corps uniforms, but there are few 
other similarities as the group mem- 
bers introduce themselves: "Hello. 
My name is , and I'm an 


The 15 patients in Naval Regional 
Medical Center Yokosuka's Alcohol 
Rehabilitation Unit (ARU) represent 
a variety of military ranks, jobs, 
years in service, backgrounds, and 
attitudes. The youngest group 
member is 19, the oldest 38. Some 
are completing their first day in the 
ARU treatment program, while 
others approach their sixth and final 

The Yokosuka ARU is one of 14 
such facilities the Navy sponsors in 
the U.S. and at oversea naval bases. 
The unit will accept up to 15 people 
at a time for a six-week clinical 
program stressing the principles of 
Alcoholics Anonymous. These pro- 
grams are similar to the programs 
available at the four much larger 
Alcohol Rehabilitation Centers that 
the Navy has set up in the U.S. 

The unit at Yokosuka is under the 
direction of the medical center's 
chief of psychiatry. Senior counselor 
for the ARU is Chief Petty Officer 
Ron Covey — a recovered alcoholic. 

"I use my own history as an alco- 
holic to relate to the patients," 
Covey says. "It's not a stigma that I 
can't talk about. If my experiences 
may help somebody — well, there's 
almost nothing I wouldn't do to help 
an alcoholic get well." 

BUI of fare. On arriving at the 
unit, the applicant answers a brief 
questionnaire about his general and 
alcohol-related history. "We look 
for problems like charges of driving 
while intoxicated or possession of 
alcohol aboard ship, unauthorized 
absences, and a drop in perform- 

ance marks," Covey explains. "It 
gives us a clearer picture, but we 
don't use information to label or 
classify. The only person who can 
really label anyone an alcoholic is 
the alcoholic himself." 

After an interview with the ARU 
staff, the applicant may be admitted 
to NRMC Yokosuka as an inpatient. 
"He's considered a patient because 
alcoholism is a disease," says 
Covey, "and like any illness it has 
physical, mental and emotional 
traumas attached." 

Chief Petty Officer Ron Covey 

'Nothing I wouldn't do to help' 

For the next six weeks the ARU 
staff uses every method at their dis- 
posal to help the patient help him- 
self. In the mornings, the bill of fare 
includes educational movies, large 
and small group discussions, physi- 
cal therapy, and "rap" sessions 
with the staff. Afternoons are spent 
on field trips and listening to guest 

A main feature within the sched- 
uled activities is the weekly trip to 
Kehin Kamata's intercultural Alco- 
holics Anonymous meeting. "It's 
led by a recovered alcoholic Catholic 
priest and about half of the mem- 
bers are Japanese and half are 
American," says Covey. "The 
group itself makes the vivid point 
that alcoholism is not cultural or 

racial, and has no regard for fi- 
nances, age, or sex." 

Bitter problem. Back at the Yoko- 
suka ARU, Navy patients gather in 
the conference room to discuss their 
reasons for being in the program. 
Responses vary according to how 
long the person has been in the 
ARU; whether he had volunteered 
for the program, been sent by his 
command, or referred from another 
ward in the medical center; and how 
he perceived his drinking problem. 

"Alcoholism is a form of idolatry 
for me," says an older patient. "I 
worship the stuff in the bottle — but 
at the same time, I hate it. It's taken 
a long time for me to admit that 
alcohol has become more important 
to me than anything — family, 
friends, sex, life." Nods of agree- 
ment and sad, half- smiles from 
other patients attest the bitter prob- 
lem is mutually shared. 

After 20 years in the Navy, 
another soft-spoken patient says he 
first began to realize his problem 
when he was asked to transfer to the 
Fleet Reserve. "I didn't want to 
transfer," he says. "It took a prob- 
lem to make me realize the bigger 
problem. The four weeks I've spent 
here is the longest I've gone without 
alcohol in almost 10 years — but I 
still don't want to think of myself as 
an alcoholic." 

A young man, seated away from 
the group, insists he is not an alco- 
holic, but rather is only going along 
with his command's decision to 
send him through the program. 
"It's just that I really express my- 
self better when I'm drunk," he 
says. "Sometimes I've been out 
with friends, and I've gotten into a 
little trouble— but I don't think I 
have a drinking problem. Not 

Nearby, a patient smiles. "It took 
a while for me to know that who I 
was didn't pour from a bottle," he 

Physical deterioration is cited as 
another reason for volunteering for 

U.S. Navy Medicine 

the ARU program: "When I joined 
the Navy, my blood and urine tests 
were fine. At my reenlistment phys- 
ical, I was in near-diabetic condi- 
tion. Three months later, I had 
pneumonia. I was falling apart 
mentally and physically, but I 
couldn't deal with the problems — so 
I'd go out and get 'wasted.'" 

Human worth. Viewed as a cross- 
section of the American population, 
it should be no surprise that the 
Navy has members with drinking 
problems. The National Institute on 
Alcohol Abuse and Alcoholism esti- 
mates that there are some 10 million 
alcoholics in the U.S. In a 1974 
survey by the Bureau of Naval Per- 
sonnel, about 15% of the 9,508 offi- 
cers and enlisted personnel sur- 
veyed reported drinking problems 
which impaired their duty perform- 
ance, their personal life, or both. 
Ten percent of those surveyed were 
chronic problem drinkers in need of 
immediate assistance. 

"Navy policies show that the 
Navy feels pretty strongly about the 
human worth of each individual," 
says Chief Covey. "The human 
potential that lies dormant in a 
problem drinker — well, the Navy 
feels it's worth retrieving. Ten 
years ago, even before there was an 
official program, the Navy was 
treating alcoholics at Long Beach." 

According to the Chief of Naval 
Operations, the Navy policy is that 
alcoholism is a "preventable and 
treatable disease and requires . . . 
enlightened attitudes and tech- 
niques. Prevention is the responsi- 
bility of the individual." 

But no individual is so adept at 
making excuses as an alcoholic. 
"When co-workers began to notice I 
worked better without a 'hangover,' 
I resented them," one ARU patient 
tells the group. "I skipped work, 
and eventually tried to make a 
comedy act out of being the 
'division drunk.' It didn't work — 
and I was scared." 

Various stages of alcoholism are 
interpreted by the group as fears: 
fear of legal consequences, of dis- 
charge, of friends and family be- 
coming aware of the problem, of 

death. In several patients these 
fears are coupled with a sense of 
shame over how the problem has 
hurt others. 

"I knew I was hurting everyone, 
but I still couldn't accept the idea 
that I was an alcoholic," says a man 
in his early 20's. "I still can't, 
really. It's so easy to rationalize." 

Some of the favorite rationaliza- 
tions include: 

• I'm not as bad as so-and-so. He 
drinks a full bottle a day, and I only 
drink a half. 

• I'm never late for work (no matter 
what condition I'm in). 

• I've never been really sneaky 
about it. 

the stigma of being "sober alco- 

"People are usually self-right- 
eous," one patient says. "I mean, 
how do you react when I tell you I'm 
an alcoholic?" 

A greater fear is the temptation of 
the first drink: "I'll be an alcoholic 
always — even if I never drink again. 
I know I've got to go back outside. 
Yes, I'm scared. But the difference 
is that now I've got another shot at 

"I don't look too far ahead, 
though. I've developed more confi- 
dence, motivation, and pride here — 
but I just keep thinking: 'One day at 
a time.'" 

Chief Covey discusses ARU treatment program with group 

• I don't take hard drugs. 

Temptation. When one newcomer 
admits his suspicion of the ARU 
program and speaks of "brain- 
washing techniques," older pa- 
tients emphatically object. "I felt 
like that at first," another patient 
tells the newcomer. "When I first 
came, I thought I was the only per- 
son in the world who had this kind 
of problem. For me, the ARU was 
like turning on a light in my head. 
Pieces of what the counselors and 
other patients said began to filter 
through to me. They'd explain 
something, and I'd think: 'Right! 
That's how it is.' I just wish I could 
stay here." 

Patients also discuss their fear of 

The Navy retains its Alcoholism 
Prevention Program because the 
program works — and works well. 
The program claims a 70% recovery 
rate based on the criteria of former 
patients who have returned to active 
duty, been recommended for re- 
enlistment, or recommended for 
promotion within one year following 

"I think the reason for the 
Navy's success is the people in the 
program," says Chief Covey, 
"About half of the directors, coun- 
selors, and staff are sober alco- 
holics. They understand the pain of 
alcoholism — and they know what 
they're talking about." 
— J02 Betty Pease, USN 

Volume 68, September 1977 

Not for Flight 
Surgeons Only 

Navy primary care physicians in- 
terested in aviation medicine can 
now get involved in the field without 
making a full commitment to flight 
surgeon training. A short course 
given at the Naval Aerospace and 
Regional Medical Center in Pensa- 
cola prepares physicians for duty as 
aviation medical officers (AMOs) — 
trained to care for aviation person- 
nel when no flight surgeon is avail- 

"AMO students learn that seem- 
ingly minor physical problems may 
have a big effect on the ability of 
flight personnel to perform well," 
says CAPT M.G. Webb (MC), 
director of BUMED's Aerospace 
Medicine Division. 

AMOs are introduced to the phys- 
iological and environmental stresses 
encountered by aircrewmen and 
aviation support personnel: hypox- 
ia, dysbarism, spatial disorientation 
and acceleration, as well as thermal 
changes, radiation and noise. They 
are also trained in the physical 
standards for all types of aircrew- 
men, and learn to perform a full 
range of flight physical examination 
procedures. Sessions on operational 
medicine cover aerospace psychol- 
ogy, aviation safety, and alcohol 
abuse, among other topics. 

Details of the training can be 
found in BUMED Instruction 
1520.24 of 1 April 1977. 

The AMO program was devel- 
oped as a partial solution to the 
Navy's shortage of flight surgeons. 
On completing training, AMOs are 
stationed in branch clinics at Naval 
or Marine Corps air stations and 
other installations with large num- 
bers of naval aviators — the Naval 
Weapons Center at China Lake, 
Calif., for example. 

AMO classes are held three times 
a year. Interested medical officers 
should apply to BUMED Code 511 
through their chain of command. 

Seaman from Panamanian oil tanker disaster is rushed to NRMC Camp Lejeune 

Tanker Evacuees Get 
Emergency Care 

An early-morning explosion 
aboard the oil tanker Claude Con- 
way 125 miles off the North Carolina 
coast last March sounded the alert 
for an emergency medical team at 
Naval Regional Medical Center 
Camp Lejeune. 

The Panamanian-registered tank- 
er broke in two on 20 March, with 
crew members suffering nearly 24 
hours' exposure to rough seas be- 
fore their rescue. 

A Coast Guard helicopter brought 
the first five evacuees to the medi- 
cal center on 21 March, where they 
were met by a team of Navy physi- 
cians, nurses, and hospital corps- 
men. These first five patients were 
the most seriously injured of the 
crew. One man arrived with burns 
over 90% of his body, and was later 
transported to the burn center at 
Brooke Army Medical Center, Fort 
Sam Houston, Tex. 

Thirteen less seriously injured 
men arrived on a second Coast 
Guard helicopter at noon. They 
were escorted to waiting ambu- 

lances by the same emergency 
squad of Navy hospital corpsmen, 
Marines, and civilian firemen who 
helped transport the first evacuees 
to the medical center. 

In all, 18 survivors were brought 
to NRMC Camp Lejeune, Nine more 
men were taken aboard a Liberian 
tanker en route to Baltimore. An- 
other 12 crewmembers could not be 
accounted for. 

The 18 survivors who reached 
NRMC Camp Lejeune were taken to 
the emergency room where the 
medical staff treated injuries that 
included burns, fractures, cuts and 
abrasions. Several hypothermia 
machines were set up to raise the 
critically low body temperature of 
men exposed to wind and water for 
such a long time. 

Eleven of the men were released 
from the hospital the day after their 
admission. The other patients re- 
quired longer hospitalization, but 
all subsequently recovered and re- 
turned to their homelands. 

— Story and photos by CPL Larry Lindsey 
U.S. Navy Medicine 


Patient Education: A Tool for Efficient 
Health Care Delivery 

LCDR Robert Downs, NC, USN LCDR Paul Eklund, MSC, USN LCDR Roger Shaver, MSC, USN 

/ know of no safe depository of the ultimate 
powers of society but the people themselves; and, 
if we think them not enlightened enough to exer- 
cise their control with a wholesome discretion, 
the remedy is not to take it from them, but to 
inform their discretion by education. 

Thomas Jefferson 

Many patients who frequent the doctors' offices, 
medical clinics and hospitals of this nation do not real- 
ize that they can exercise significant control over their 
own physical well-being. They do not understand the 
nature of illness nor what constitutes sound health 
practices. They are unaware of the limitations inherent 
in any health care delivery system. 

In a Louis Harris study carried out in 1971 for the 
Blue Cross Association (1), 65% of the respondents 
believed they could recognize the symptoms of most 
important illnesses. But when asked specifically about 
the "seven danger signs" of cancer — the second lead- 
ing cause of death in the U.S. — only 13% of the people 
surveyed could identify four or more signs; 17% could 
identify only one sign, while 30% could identify none. 

Surveying knowledge of heart disease — the number 
one cause of death in the U.S. — the Harris Study found 
that only half the respondents were able to volunteer 
more than one symptom that might indicate a heart 
condition or heart attack. Twenty- seven percent were 
unable to name any such symptoms. 

The Harris Study concluded that in the U.S. a critical 
information void exists about major illnesses. There is a 
large gap between the public's presumed knowledge 
about major illnesses and the knowledge they are able 
to demonstrate. 

To help close this gap, health care providers must 
create programs to stimulate the demand for preventive 
health care information. The public's attention must be 

From the National Naval Medical Center, Bethesda, Md. 20014, 
LCDR Downs is patient coordinator for the NNMC Psychiatric Ser- 
vice, LCDR Eklund is an optometrist assigned to the Eye Clinic, and 
LCDR Shaver is with the Pharmacy Service. 

focused on health care problems before they become 
chronic. Examples of noteworthy efforts to promote 
better health habits include recent campaigns against 
smoking and drug abuse, and encouraging physical 
fitness and proper nutrition. 

Does consumer education get results? Consider the 
public's response to the growing awareness that the 
cost of a serious illness today can be catastrophic. Fol- 
lowing the national emphasis on illness-centered care, 
the public is pressuring Congress to provide a national 
health insurance program to cover ever-increasing hos- 
pital costs. Yet these same concerned citizens overlook 
the role health education can play in reducing runaway 
costs and helping to lessen the burden on our nation's 
health care delivery system. 

The ultimate goal of the health care system is to help 
individuals change their behaviors and take the preven- 
tive and curative actions that promote, protect, and 
maintain their own optimum level of health (2). In 
support of this goal, more information about maintain- 
ing good health must be made available to the public. 
The availability, relevancy, and accuracy of this infor- 
mation will influence how the public makes use of 
health services. Programs stressing the importance of 
primary and secondary prevention can educate the 
public to adopt lifestyles conducive to a long and pro- 
ductive life. Healthier lifestyles will in turn lead to more 
efficient and less costly use of health care services. 

Health education can also help lower costs for pa- 
tients who require hospitalization. In a study of patients 
undergoing intra-abdominal surgery at Massachusetts 
General Hospital (3), patients who received health 
education required less narcotics and were discharged 
an average of 2.7 days earlier than a control group of 
patients who received no health education. 

Health education can help lower the number of pa- 
tients seeking emergency services, relieving some of 
the burden on acute treatment centers. A study of 58 
asthmatic patients revealed that, in a four-month 
period, patients who participated in health education 
programs made 55 fewer visits to the emergency room 
than did the control groups of patients (3). 

Volume 68, September 1977 

Most people are not self-motivated to seek out and 
use educational materials about health care. A strong 
promotional program is required that will expose the 
consumer to health information again and again. Es- 
sential steps in setting up such a program include: 

• Identifying types of consumers to be educated 
through the program. 

• Developing relevant and effective messages. 

• Selecting the best means for transmitting these mes- 
sages to intended consumers. 

• Determining the cost of the patient education pro- 
gram as related to its potential return. 

Patient education has the support of the Navy Sur- 
geon General, who earlier this year directed medical 
facility commanding officers to set up health care con- 
sumer councils and establish local patient education 


Any health care facility has the responsibility of 
meeting the demands of its patients. Problems arise, 
however, when the patient's health care demands do 
not match his health care needs as determined by the 
provider (4). The result: inefficient use of health care 

Today the Navy Medical Department is caught in the 
squeeze between an increasing patient demand for 
services and a concomitant decrease in resources. The 
consumer health education program called for by the 
Surgeon General will help balance demand against 
capability and actual need. For example, the primary 
objective of the health care consumer council is to de- 
termine patient demands through a free exchange of 
ideas and information between consumer representa- 
tives and representatives of the health care delivery 
team. The councils give beneficiaries a forum to 
express their opinions about Navy health care; at the 
same time, the councils give hospital staff members an 
opportunity to discuss and explain policies, practices, 
problems, and other important matters. 

On the council, the medical facility is usually repre- 
sented by its director of clinical services, patient affairs 
officer, nursing supervisor, and a dental officer. Other 
council members representing the hospital are a 
command-sponsored ombudsman and the senior chief 
petty officer. These members describe the policies and 
problems of the medical facility, and explain what ser- 
vices are available. Most important, they listen to the 
consumers and answer questions. 

The consumer members represent various area or 
tenant commands, wives' groups, retired military 
members, volunteer services, civilian personnel, and 
other organizations whose membership includes Navy 
health care beneficiaries. The consumer representa- 
tives bring the opinions of the medical facility's pa- 
tients to the attention of the council. But to be effective, 
the representatives must make themselves known to 

health care consumers; they must be readily available 
and actively seek out questions and opinions. 


The patient education program is directed towards 
the "well" and the "worried well" to help them use 
Navy health care resources wisely. Clinic visits by 
worried well patients can probably be significantly re- 
duced through effective patient education. As health 
care costs continue to rise, it becomes increasingly im- 
portant to educate our beneficiaries about health care. 

The general objectives* of a patient education pro- 
gram are: 

1) To minimize the workload of the health care profes- 
sional . 

2) To increase patient satisfaction with the care re- 

3) To improve therapeutic effectiveness. 

4) To economize in using health care resources. 

The patient needs to know why, when, where, and 
how to enter the Navy health care delivery system. 
Here are some ways naval medical facilities can provide 
this information: 

• Encourage beneficiaries to become familiar with how 
the facility is organized and with the hours various 
clinics are open. 

• Encourage patients to make appointments for care, 
except in emergencies. 

• Encourage people to keep their immunizations up to 

• Teach good personal hygiene practices. 

• Throughout the year, inform people when certain 
seasonal illnesses will be prevalent. Explain how to 
recognize these illnesses and remedy them at home. 

• Teach people how to prevent or manage their own 
minor illnesses and injuries. 

• Teach people to recognize and seek prompt attention 
for significant illness. 

• Increase the patient's understanding of his own 
health problems, and of therapeutic measures pre- 
scribed or undertaken. 

• Explain the capabilities of the emergency room and 
discourage its use for other than emergency problems. 

• Teach patients to differentiate between health care 
problems that require a physician's attention and prob- 
lems that can best be handled by other health care per- 

• Alert people to the hazards of keeping medications in 
the home, and teach them how to properly dispose of 
old or surplus medicines. 

• Teach patients the importance of maintaining accu- 
rate and complete medical records. 

• Encourage patients to seek all their health care at the 
same facility so the continuity of their care will be un- 

*Adapted from Naval Hospital Patuxent River Instruction 1510.3 of 
IS Feb 1977. Subj: Patient Education Program. 


U.S. Navy Medicine 

broken and duplicate tests and examinations can be 

• Develop surveys or questionnaires to encourage pa- 
tients to record their impression of the service they 

There are many ways to provide consumers with the 
information they need. Among them: 

• Instruction sheets explaining therapeutic as well as 
diagnostic procedures. 

• Pamphlets describing minor diseases and offering 
advice for home care. 

• Health care bulletins to announce changes in clinic 
schedules, remind people to get immunizations, and 
disseminate information about seasonal illnesses. 

• Orientation briefings and printed materials for new 
residents and retiring personnel. 

• Presentations designed to inform wives' clubs, 
school children, scout groups and so forth about health 

• Audiovisual programs on specific diseases, thera- 
peutic regimens, and diagnostic procedures. 

• A Hot Line for pediatric health information. 

• Local radio and television spot announcements on 
health care topics. 

• Stories in local and base newspapers and newslet- 

• An Action Line telephone, operating 24 hours a day, 
seven days a week, with messages relayed to the CO's 
office and responses made within 24 hours when possi- 
ble, and within 72 hours at the latest. 

• Information made available through existing com- 
munity programs. 

Because consumers are the benefactors of this effort, 
they should also bear some of the responsibility for 
health education. They must avail themselves of the 
information offered. Consumers, as well as providers of 
health care, must understand that the worst time to 
educate a patient is while he is sick. Our beneficiaries 
must read the pamphlets, watch the audiovisual pro- 
grams, and attend the special presentations before — 
not after — a crisis occurs. 

One final consideration: health care facilities some- 
times lose sight of the fact that they exist to serve the 
patient, not to benefit the practitioner. Too often, staff 
members have the attitude "this would be a great place 
to work if there were no patients." No one with such an 
attitude can deliver really good patient care. Quality 
care can only be dispensed when health care providers 
are both efficient and courteous. 


To evaluate how well the Surgeon General's directive 
on patient education was being observed, we took a 
close look at the program at Naval Hospital Patuxent 
River, Md. This is a fully accredited, 23-bed hospital 
which supports a large outpatient clinic. Among the 
specialty services provided are family practice, pediat- 

CDR James R. Erie (MSC) 

Concern for the community's health 

ric surgery, orthopedics, internal medicine, Ob/Gyn, 
and emergency room care. 

Located on the Naval Air Station, Naval Hospital 
Patuxent River is the area's only military source of 
health care treatment and information. This relative 
isolation should give greater validity to our evaluation 
of the patient education program's impact. 

When the Surgeon General's directions were issued 
in January 1977, Naval Air Station Patuxent River al- 
ready sponsored a consumer panel through which 
representatives of the many station sub-units and 
wives' groups could discuss ideas and problems with 
representatives of the commissary and exchanges. 
Since this was already an active and effective means of 
exchanging information, the hospital commanding 
officer, CDR James R. Erie (MSC), elected to add Med- 
ical Department representatives to the existing panel 
rather than set up a new panel. 

At the hospital itself, a series of staff meetings was 
undertaken to discuss the importance of courteous, 
effective, and efficient treatment of patients. Also, all 
new arrivals to the staff received indoctrination pro- 
grams designed to instill these attitudes. Even after the 
initial discussions were completed, staff meetings have 
been continued as a forum for suggestions on ways to 
give better service. At these meetings, complaints re- 
ceived at the hospital and at other facilities are dis- 
cussed to determine what went wrong and how the pa- 
tient might have been better cared for. Pamphlets and 
other written material stressing the theme of consumer 
rights support the discussion. 

During reporting aboard procedures, newcomers to 
NAS Patuxent River are briefed on the health services 
available. The briefing is supplemented by an informa- 
tional pamphlet, "This Is Your Hospital," which lists 
the hospital's hours of operation and gives a brief de- 
scription of all services. 

Volume 68, September 1977 


(Below) Videocassefte players provide health education programs in clinic waiting 
rooms. (Right) LCDR M. Murphy, family practitioner, helps a young patient relax 
during examination. 

Because the hospital CO believed the patient educa- 
tion program would be more effective if consumers 
were aware of the hospital's commitment to and con- 
cern for the health of the community, staff members 
now accept invitations to speak before responsible com- 
munity groups. Lecture topics are diverse: one well- 
received lecture covers health benefits available 
through CHAMPUS; other popular topics include first 
aid, venerea] disease, and child abuse. It is not unusual 
for these lectures to be given at 0200 in the ready room 
of one of the various squadrons. Extensive first-aid in- 
struction is given to all search and rescue teams. Also, 
all community members are welcome to attend cardio- 
pulmonary resuscitation training courses given twice 
weekly; the effectiveness of this training has been 
enhanced by the local wives' club's gift of equipment 
and mannequins. 

During the last outbreak of influenza, the principal of 
the local elementary school asked the hospital to send a 
speaker for a PTA meeting. A pediatrician attended to 
discuss the influenza outbreak and teach parents how to 
manage the illness at home. Also, local school children 
and scout groups regularly tour the hospital, where 
they receive important health care information they can 
pass on to their parents. 

With the lecture program solidly established as a 
community resource, the hospital began a more com- 
prehensive program of education, zeroing in on specific 
diseases and teaching patients how best to use the 
health care delivery system. 

The program helps make educational material avail- 
able to consumers at every opportunity. Outside the 
hospital, "Welcome Aboard" packets are stuffed with 

Numerous health pamphlets are available 

health information and pamphlets, and flyers are 
placed at strategic points around the air station. All this 
information is brief and kept up to date, reflecting the 
health problems most common during the different 

The greatest amount of information is found in the 
reception areas of the hospital's clinics. A videocassette 
player is moved to the various waiting areas to show 
health education programs produced by the Navy 
Health Sciences Education and Training Command in 
Bethesda. Booklets produced by national associations 
such as the Red Cross and the Society for the Blind are 


U.S. Navy Medicine 

displayed. In addition to this commercial information, 
each clinic has developed its own pamphlet that de- 
scribes common health problems and their treatment. 
Patients are encouraged to call the clinic if they have 
questions about any health problem. 

The clinics also are beginning to use a local variation 
of the Tel-Med telephone communication system. Here 
again, the talents of the staff are used rather than com- 
mercial tapes so the material can be tailored to the 
specific health needs of the local community. The plan 
is to vary the information each month. When a particu- 
lar health problem arises, a new tape will be produced 
to inform patients about it. These tapes are supple- 
mented by printed material distributed throughout the 

The hospital's pharmacy, optometry, and physio- 
therapy services also prepare tapes to teach patients 
how to make the best use of those services. 

Locally produced printed material carries telephone 
numbers patients can call for further information. 
When such calls come in, the clinic receptionist records 
the patient's name, telephone number, and presenting 
complaint. The patient is told that his call will be re- 
turned promptly. The receptionist then retrieves the 
patient's health record and takes the record and the 
presenting complaint to the clinic's nurse screener. If 
the complaint is routine, the nurse will return the pa- 
tient's call and handle the problem. If the complaint is 
complicated, the nurse will confer with the clinic physi- 
cian, and then either the nurse or the physician will 
return the call. If the patient needs to be seen in the 
clinic, an appointment will be made. All requests for 
treatment are documented in the patient's health 

While the hospital's education program is still being 
expanded, early efforts have begun to show results. For 
example, clinic appointment schedules have been 
changed so each physician has six appointments each 
day reserved for patients with acute problems (defined 
as patients who must be seen within 24 hours). Another 
six 15-minute "hold" periods are kept available for 
walk-in patients. Emergency room personnel now 
evaluate patients as they arrive; patients who do not 
require emergency care are referred to the clinic ap- 
pointment desk where they are given an appointment to 
be seen later, usually within 48 hours. All patients are 
instructed on the importance of keeping appointments 
or cancelling them in sufficient time to permit other pa- 
tients to be seen. 

Before the new system was instituted, all acute care 
and hold appointments were filled; about 20% of 
scheduled patients failed to keep their appointment. 
Within three months, under the new program, the 
number of emergency room visits had dropped. 
"No-shows" were down to 10% or less. Acute care 
appointments and "hold" appointments were only 
partially filled. Patients who must be seen by a physi- 
cian soon after they call in for the telephone consulta- 

tion or arrive in the emergency room are now scheduled 
for an appointment that same day. 

Patients who must wait more than ten minutes past a 
scheduled appointment time are told the reason for the 
delay. After a 20-minute delay, patients are given three 
options: they may continue to wait, they may see 
another physician, or they may reschedule their ap- 

During these same three months, there was a steady 
increase in telephone consultations and a decrease in 
clinic visits. This change is especially significant when 
compared with other treatment facilities which are 
sometimes overwhelmed with patients — during out- 
breaks of influenza, for example. 


The field of health care delivery has only recently 
begun to appreciate the use of marketing principles. In 
its Consumer Health Education Program, the Navy 
Medical Department makes use of one of these prin- 
ciples: promotion. By setting clear objectives, Naval 
Hospital Patuxent River has shown that a patient edu- 
cation program can improve the efficiency of health 
care delivery. 

The first objective is to establish direct communica- 
tion between provider and consumer. Useful here are 
printed materials, audiovisual aids, lectures, and so 

The second objective is to stimulate demand by in- 
volving the community in health-related issues. 

Achievement of the third objective — educating pa- 
tients to discriminate between services — was evidenced 
by decline in the use of the emergency room and the 
concomitant increase in the use of more appropriate 
entry points into the health care system. 

That the fourth objective — to recognize the value of 
preventive health care — was successfully met is 
demonstrated by consumer requests for preventive 
health care programs to be given at various meetings 
throughout the community. 

The value of a patient education program can only be 
determined over a long time. Despite its initial accom- 
plishments, the Patuxent River program has not been 
used long enough to measure its ultimate effectiveness. 
The prospects for its success look good, and other naval 
medical facilities may wish to study and apply its 


1. The Public's Need for Information About Health Problems. A 
Louis Harris study for the Blue Cross Association, Washington, DC, 

2. Simonds SK: Current Issues in Patient Education. New York: 
Core Communications in Health, Inc., 1974. 

3. Raccella EJ: Potential for reducing health care costs by public 
and patient education. Public Health Rep 93(3):223, May- June 1976. 

4. Feldstein PJ: Research on the Demand for Health Services. 
Milbank Mem Fund Quart 44(supplement):128-65, July 1966. 

Volume 68, September 1977 


Navy Diving Biomedical Research and 
Development: The NMRI Program 

Mary M. Matzen 

The Naval Medical Research Institute (NMRI) in 
Bethesda, Md. — a multidisciplinary research facility 
sponsored by the Naval Medical Research and Develop- 
ment Command — is the Navy's lead laboratory for 
diving biomedical research and development. 

Investigation into the biomedical problems of fleet 
divers has been under way at NMRI since 1942. Today, 
research efforts range from finding timely solutions to 
diving medical and operational problems encountered 
within the current 1,000-foot diving capability, to devel- 
oping methods for effective diving to 2,500 feet by 

NMRI diving researchers will soon have a greatly ex- 
panded research capability: a new hyperbaric research 
facility, which will house a wet pot capable of simulat- 
ing depths to 3,300 feet of seawater (fsw) and will in- 
clude living quarters and support for divers under pres- 
sure. With this capability, NMRI can conduct advanced 
human hyperbaric research in its own laboratory. 

For animal studies, the new complex will provide 21 
smaller chambers capable of simulating 3,300 fsw. A 
mobile service chamber will permit test animals to be 
held under pressure while their chambers are cleaned; 
such an arrangement will enable researchers to carry 
out long-term studies under pressure. 

Animals are used initially to test techniques de- 
veloped for eventual human experimentation — drug 
interactions, for example.* Animals are also used in 
experiments where use of human subjects is not 
feasible: for example, deep electrodes are implanted in 
animals to establish the relationship between brain 
activity and hydrostatic pressure. 

Investigators also test new concepts on animal 
models and only after thorough testing will move on to 
human experimentation, with volunteer Navy divers 
serving as subjects. One example: an animal experi- 
ment involving the estimation of time has contributed 
to the understanding of how human divers adapt to re- 

From the Behavioral Sciences Department, Naval Medical Re- 
search Institute, National Naval Medical Center, Bethesda, Md. 

* Animal experiments are conducted in accordance with the principles 
set forth in the "Guide for the Care and Use of Laboratory Animals, " 
Institute of Laboratory Animal Resources, National Research Council, 
Department of Health, Education and Welfare, Publication No. (NIH) 

peated hyperbaric exposures. Time estimation in 
animals is a sensitive response to experimental manip- 
ulations. It is also a precise technique for measuring 
human performance. In an adaptation study by Thomas 
and associates (7), rats were trained by operant tech- 
niques to press a lever at regular time periods. Stable 
performance baselines were established for each 
animal. The training was done at "surface' ' pressure (1 

The rats were initially exposed to hyperbaric pres- 
sure in a simulated pressure-chamber dive to 200 fsw 
while they were breathing compressed air. This initial 
exposure to pressure disrupted and modified the estab- 
lished performance baseline by substantially increasing 
responses. Further experimentation showed that when 
intervals of time were allowed to elapse between sub- 
sequent dives, the timing precision of the rats at 200 
fsw was not disrupted; the rate of response returned to 
surface baseline values. 

When Navy divers were asked to punch buttons 
under the same environmental conditions, the results 
were similar. 


Many of the diver's physiological problems stem 
from the effects of pressure on his body. This pressure 
is made up of two forces: the weight of the water over 
the diver, and the weight of the atmosphere over the 
water. With each 2-foot increase in depth of seawater, 
pressure increases by almost one pound per square 
inch (psi). Each 33 feet of descent in seawater increases 
the pressure by an additional atmosphere (14.7 psi). 
The effects of pressure can be grouped into two cate- 
gories: direct or mechanical effects, such as the com- 
pression of body air spaces during descent; and indirect 
effects, which result from changes in the partial pres- 
sures of gases in the breathing medium (2). 

The breathing medium means life to the diver, but it 
is also the source of many of his physiological problems 
because, under hyperbaric pressure, the diver's body 
interacts with the breathing gases. The breathing 
equipment itself, which delivers and regulates the 
gases, can also cause or extend many of the diver's 

Because of its ready availability and low cost, com- 
pressed air is the breathing mixture most commonly 
used for dives as deep as 150 fsw. Mixed gases are used 


U.S. Navy Medicine 

The first section of NMRI's new hyperbaric research facility arrived in March. The "wet pot" is in the foreground. 

(Above) Dry chamber is unloaded and (right) installed in NMRI lab. Second section arrived in July. 

Volume 68, September 1977 


Hyperbaric chambers used for test animals 

when the divet descends deeper and stays longer. Al- 
though all breathing mixtures must supply a limited 
amount of life-supporting oxygen, toxicity occurs when 
the diver breathes excessive amounts of oxygen under 
pressure. Nitrogen or helium are routinely used as dilu- 
ents for oxygen, depending upon the depth and dura- 
tion of the dive. But these inert gases have their own 
unique disadvantages. For example, nitrogen causes 
narcosis and increased breathing resistance, and re- 
quires the diver to undergo longer periods of decom- 
pression. Helium causes rapid loss of body heat, 
"Donald Duck" speech, and altered excitability of the 
nervous system. 

Basic to solving these problems is the need to define 
inert gas transport and elimination in the body. Inert 
gases used as diluents for oxygen are taken up by body 
tissues under pressure, in a process called "satura- 
tion." As the pressure is reduced, the gases must be 
returned from these tissues — that is, the tissues are 
desaturated — but in a form that does not inflict acute or 
chronic injury. To avoid such injury, safe decompres- 
sion schedules are vital. But such decompression 
schedules must be based on a quantitative understand- 
ing of inert gas transport in the human body; this un- 
derstanding does not yet exist. 

Decompression is defined as a release of pressure, 
and decompression sickness as the "overt illness which 
follows a reduction of environmental pressure, suffi- 
cient to cause the formation of bubbles from the gases 
which are dissolved in the tissues" (3). The importance 
of carefully controlled pressure reduction has long been 
established, but little is known about its effect on 
bubble formation in living tissue. 

The symptoms of decompression sickness are the 
result of bubbles forming in the vascular system or 
tissues. These symptoms can be as innocuous as tem- 
porary skin rash or mild discomfort in the joints and 

muscles, but may also include paralysis, numbness, 
hearing loss, vertigo, unconsciousness, and death (2,4). 
Decompression sickness is treated by recompressing a 
diver to a pressure sufficient to allow the bubbles to 
dissolve. When the symptoms have cleared, decom- 
pression schedules may be used to decompress the 
diver to surface pressure. 

New modes of therapy for decompression sickness 
are needed, as well as optimal decompression tables for 
manned saturation and subsaturation dives. NMRI re- 
searchers, focusing on the pathophysiology of decom- 
pression sickness (5), are attempting to: 

• define the mechanisms by which central nervous 
system and joint dysfunction occur in decompression 

• establish the impact on cardiopulmonary function of 
the bubbles formed during the decompression process. 

• elucidate the interaction of these bubbles with the 
microcirculation (6,7). 

The results of this work can be applied to the clinical 
problems of cerebral air embolism, spinal cord trauma, 
and stroke. An ultimate goal is to develop objective 
criteria for diagnosing and predicting decompression 
sickness, as well as methods for assessing the adequacy 
of decompression and for detecting tissue damage. 


To increase diver safety and effectiveness, research- 
ers at NMRI are also striving to understand the basic 
mechanisms that cause inert gas narcosis. Through 
animal studies, they are attempting to determine the 
site of action of narcotic gases and to understand the 
alterations in membranes that narcotic substances may 
induce. The interaction of inert gas narcosis and en- 
vironmental factors such as cold, high concentrations of 
inspired carbon dioxide, compression rates, and the 
like must be assessed as they relate to altered cognitive 
and neuromuscular performance of underwater tasks. 

The toxic effects of oxygen are related to the oxygen 
partial pressure in the breathing medium. Yet elevated 
partial pressures of oxygen are widely used to speed up 
decompression and to treat decompression sickness, air 
embolism, and other clinical problems such as 
gangrene and carbon monoxide poisoning. Determin- 
ing the limits of safe oxygen partial pressures to which 
divers can be exposed is further complicated by the 
variation in oxygen tolerance among individuals and in 
one individual from day to day. Individual tolerances 
also vary between work and rest exposures and wet and 
dry environments. These considerations affect all 
phases of diving as well as the design of diving equip- 

The syndrome of oxygen toxicity is being studied at 
NMRI in intact animals. Researchers are also assessing 
in organ systems of animals the cellular and biochemi- 
cal changes that precede and accompany the body func- 
tion alterations seen in oxygen toxicity. The search is 


U.S. Navy Medicine 

for a way to modify an organism's susceptibility to 
oxygen toxicity. 

The nature of the underwater environment itself is a 
continuing hazard to the respiratory and circulatory 
systems. NMRI investigators are trying to determine 
the "normal" respiratory state for divers, and to estab- 
lish safe tolerance limits for carbon dioxide retention. 
Studies are also under way to evaluate the effects of 
immersion, pressure breathing, external impedance to 
breathing, and gas density as they relate to the me- 
chanical work of breath ing, the energy cost of breath- 
ing, and the efficiency of the respiratory muscle. The 
amount of ventilatory loading a diver can tolerate and 
the high-pressure nervous syndrome may constitute 
limits (as yet undefined) to man doing useful work 
under water. Information from the NMRI studies can 
also be applied to clinical problems of respiration, such 
as emphysema and chronic lung disease. 

A diver's cardiovascular function is affected by 
hydrostatic pressure, the nature of the inert gas in the 
environment, and the high partial pressure of oxygen. 
The ultimate goal for this work at NMRI is to determine 
the depth limit at which the circulatory system will 
function properly. Initially, animal studies will assess 
the effects of increased pressure and various gas mix- 
tures on the physiological components of the circulatory 
system at graded hyperbaric pressures. Studies using 
human volunteers will assess cardiovascular function as 
it relates to submaximal work in mixed-gas environ- 
ments at low and high pressures, in wet and dry 
environments, during long-term exposures, and during 
compression and decompression. 

Cold is particularly penetrating in the diving environ- 
ment: underwater work in 25° C water produces 
thermal stress in less than an hour. NMRI scientists are 
now examining cardiovascular, pulmonary, and endo- 
crine response to thermal stress in the immersed diver 
at shallow depths (8) by monitoring cardiac and respira- 
tory rates, pulmonary ventilation, oxygen and carbon 
dioxide production, and core temperature. Blood and 
urine samples are obtained from each diver before, 
during, and after exposure, so researchers may analyze 
stress hormones and other biological variables. 

Related work focuses on devising methods to 
precisely quantify, by heat-flux sensors and thermis- 
tors, the respiratory and skin heat loss of divers. The 
goal is twofold: first, to devise equations that predict 
heat loss and body temperature for any combination of 
ambient pressure and temperature; second, to define 
the tolerable range of deviation from normal skin-body 
temperatures under hyperbaric conditions. The rela- 
tionship between body heat loss, temperature, and 
performance will be investigated and defined. The 
various levels of body heat loss will be correlated to 
changes in performance on underwater tasks requiring 
manual dexterity, a sense of touch, strength, and 
cognitive function — tasks such as would be encountered 
in underwater rescue or underwater construction and 

Work sled ergometer measures diver's performance 

maintenance, for example. This information could lead 
to the design of equipment to ensure that divers main- 
tain the body heat they need for top performance; it will 
also provide guidelines for diver rescue and for coping 
with the heat loss a diver experiences when his equip- 
ment fails. The possible relationship between thermal 
balance and decompression sickness will also be inves- 


The study of underwater performance and perform- 
ance physiology is crucial to the Navy's diving opera- 
tional goals. The ultimate performance goal is to enable 
Navy divers to carry out their missions with little or no 
performance degradation as a result of the environ- 
ment, diving techniques, or equipment. To attain this 
goal, diving officers must be able to predict and assess 
diver performance. At present, there is no body of in- 
formation that clearly defines the safe working limits of 
the diver relative to his task, equipment, physical 
endurance, and physiological weakening. 

In general, the factors that contribute to diving per- 
formance limitations fall into three categories: sensory 
limitations, cognitive limitations, and motor perform- 
ance limitations. A diver's visual field and depth per- 
ception are severely limited under water; his judging, 
estimating, and discriminatory abilities may be affected 
by the dive conditions, and his motor performance is 
degraded by cold, neutral buoyancy, and the limited 

A particular motor degradation, the "high-pressure 
nervous syndrome," occurs at depths of about 1,000 
fsw and beyond. This syndrome is believed to result 
from a disturbance of central nervous system function. 
Its symptoms appear as electroencephalographic irreg- 
ularities, tremor, loss of vigilance, altered posture and 

Volume 68, September 1977 


balance, fatigue, and microsleep. Researchers at NMRI 
are investigating the effects of temperature and rate of 
compression on the high-pressure nervous syndrome to 
determine whether a diver can adapt to this condition, 
and if so, to what degree. The use of additive gases, 
such as higher percentages of nitrogen, are being in- 
vestigated as a way of reducing these symptoms. Also, 
the basic mechanisms of the high-pressure nervous 
syndrome are being studied to obtain further informa- 
tion about the onset, nature, and treatment of this con- 

There is yet another factor in performance degrada- 
tion under hyperbaric conditions: the effect of pharma- 
cological agents and compounds. Because of accidents, 
decompression sickness, minor illnesses, pain or dis- 
comfort, divers are often taking some medication. Yet 
drugs that are considered safe and effective at surface 
pressure may have an altered effect on biological sys- 
tems in the high-pressure environment. For example, 
some antihistamines cause behavioral changes — often 
unpredictable. The NMRI program includes a general 
pharmacologic study that has surveyed, in several 
species of animals and under hyperbaric conditions, the 
activity and toxicity of common therapeutic drugs such 
as aspirin, caffeine, antihistamines, anesthetic drugs, 
and antibiotics. Researchers are beginning to study 
ways the results of these studies can help Navy divers. 


Several tasks have been designed to assess divers' 
underwater performance: 

• the ENERPAC task, in which divers use a hand- 
operated hydraulic tool to cut into a wire roll. 

• a task in which divers maneuver a self-contained 
load-handling pontoon under water. 

• An underwater pipe puzzle assembly task developed 
at the University of California in Los Angeles (UCLA). 

• the SP 2 task— NMRI's revision of the UCLA pipe 

These tasks were used in the early 1970's to measure 
divers' performance during evaluations to determine 
whether the U.S. Navy prototype Mark XII diving sys- 
tem (see cover) was a suitable replacement for the 
standard Mark V diving system, used since 1930. 

Human engineering considerations can also provide 
much-needed information about the impact of diving 
equipment and systems on the diver's safety and per- 
formance. For example, during the evaluations of the 
Mark V and Mark XII diving systems, a biomechanical 
analysis was performed on divers wearing each suit (9). 
This analysis employed 14 biomechanical measures 
taken from dynamic anthropometry (which deals with 
range of motion and joint angle changes), and helped 
pinpoint the restrictions and limitations of the two 
diving suits, 

Human engineering assessments of tools and'hyper- 
baric systems are also under way at NMRI. The use of 

alternate work systems, such as one-atmosphere diving 
systems and manipulators, will be explored as possible 
ways to meet the Navy's goals for deep dives. 

Divers and occupants of hyperbaric chambers 
depend on their life-support systems to provide a pure 
and physiologically adequate breathing medium. It is 
therefore important to identify those toxic contaminants 
that are most likely to cause debilitating or irreversible 
effects on diving personnel. It is equally important to 
determine the specific biochemical, physiological, and 
pathological changes in diving personnel exposed to 
such contaminants under hyperbaric conditions. While 
standards exist for long-term exposure to contaminants 
in submarines, it is not yet known whether these stand- 
ards are appropriate for hyperbaric environments. 
Toxicology researchers at NMRI will evaluate such 
toxic contaminants using animal models in hyperbaric 
environments. Valid standards for human exposures in 
hyperbaric operational systems should evolve from 
these evaluations. 

Although man has been diving for centuries, little is 
known about the long-term and short-term effects of 
chronic exposures to high pressures and to the gases 
used in diving systems. As researchers define the ef- 
fects of hyperbaric exposures on the various body func- 
tions and systems, they will also be looking for ways 
that mammalian systems can adapt or acclimatize to the 
high-pressure environment. 

Outlined here are current problems being studied at 
NMRI. The research under way and planned may prove 
that these problems are not barriers to man doing 
useful work at great depths in the sea. 


1. Thomas JR, Walsh JM, Bachrach AJ, Thome DR: Differential 
behavioral effects of nitrogen, helium and neon at increased pres- 
sures, in Lambertsen CJ (ed): Underwater Physiology V (proceedings 
of the 5th symposium on underwater physiology). Bethesda, Md.: 
Federation of American Societies for Experimental Biology, 1976, pp 

2. The NOAA Diving Manual. National Oceanic and Atmospheric 
Administration, 1975. 

3. Berghage TE, Gomez JA, Roa CE, Everson TR: Pressure- 
reduction limits for rats following steady-state exposures between 6 
and 60 ATA. Undersea Biomed Res 3(3):261-271, 1976. 

4. U.S. Navy Diving Manual (NAVSEA 0994-LP-001-9010). De- 
partment of the Navy, 1973. 

5. Elliott DH, Hallenbeck JM: The pathophysiology of decom- 
pression sickness, in Bennett PB, Elliott DH (eds): The Physiology 
and Medicine of Diving and Compressed Air Work, ed 2. London: 
Bailliere Tindall, 1975, pp 435-455. 

6. Hallenbeck JM, Bove AA, Elliott DH: Mechanisms underlying 
spinal cord damage in decompression sickness. Neurology 25(4):308- 
316, 1975. 

7. Hallenbeck JM: Prevention of postischemic impairment of 
microvascular perfusion. Neurology 27(1):3-10, 1977. 

8. Hoar PF, Raymond LW, Langworthy HC, Johnsonbaugh RE, 
Sode J: Physiological responses of men working in 25.5° C water, 
breathing air or helium tri-mk. J Appl Physiol 40(4):605-610, 1976. 

9. Bachrach AJ, Egstrom GH, Blackmun SM: Biomechanical 
analysis of the U.S. Navy Mark V and Mark XII diving systems. Hum 
Factors 17(4):328-336, 1975. 


U.S. Navy Medicine 

IMAVMED Newsmakers 

The first lower jawbone trans- 
plant at a civilian medical institution 
was performed at the University of 
Cincinnati College of Medicine ear- 
lier this year. On the operating team 
was CAPT Hugh deFries (MC), 
head of the Otolaryngology Service 
at the National Naval Medical 
Center and a pioneer in mandible 
transplants and tongue reconstruc- 
tion. The transplant technique was 
developed at NNMC and has been 
performed on only 30 other patients 
— all in military or Veterans Admin- 
istration hospitals. "The Navy has 
good reason to be proud of the de- 
velopments it has achieved in medi- 
cal fields," Dr. deFries says. "Navy 
medical services are on a par with 
those of the leading medical institu- 
tions in the country." 

"The Navy — it's not just a job, 
it's an adventure," read the recruit- 
ing ads, and if you don't believe it 
ask CAPT Jack Blum (MC), San 
Diego urologist and member of the 
Ready Reserve. During his two- 
week active duty for training last 
January, CAPT Blum joined Marine 
units participating in Operation 
Jack Frost 77 at Fort Wainwright, 

Alaska. While the Marines trained 
for combat in the freezing Arctic 
winter, Dr. Blum attacked respira- 
tory infections, dehydration, and 
frozen extremities, not to mention 
an old preventive medicine problem 
of Arctic bivouac situations: yellow 
snow. He returned from the exer- 
cise with a packful of new ideas for 
the Navy's cold weather training 

Shore-based optometrists provid- 
ing comprehensive eye examina- 
tions aboard ship? It's a new 
wrinkle in health care delivery, but 
all part of Medical Department ef- 
forts to reduce the time crewmem- 
bers are away from their duties. In 
what is believed to be the first such 
program, Navy optometrists LCDR 
James F. Socks and LTJG Philip 
Dixon brought the services of the 
NRMC San Diego Eye Clinic to the 
USS Blue Ridge (LCC 19) last April 
for five days of tonometry examina- 
tions, ocular muscle tests, ophthal- 
moscopy, and slit-lamp studies. 
Assisting the officers were HM2 
Connie Fentanoza of NRMC San 
Diego and HM2 M.A. Rucker from 
the Blue Ridge medical department. 

Dixon, Fentanoza, Rucker: On the Blue Ridge 

Dr. deFries: On a par 

The program helped fulfill Navy 
requirements that workers exposed 
to microwave radiation receive peri- 
odic medical examinations. 

In the news: CAPT Donald L. 
Sturtz (MC), who took home the 9th 
annual NNMC Belly Board Award 
for outstanding contributions to 
gastroenterology . . . LTJG Guy R. 
Banta (MSC), named Navy Aero- 
space Physiologist of the Year . . . 
CAPT Robert C. Cefalo (MC), first 
Navy medical officer board certified 
in maternal-fetal medicine . . . 
RADM Maxine Conder (NC), recip- 
ient of a Distinguished Alumnus 
Award from the University of Utah 
. . . CAPT Joseph A. Pursch (MC), 
winner of the Alcoholism Council of 
Greater Los Angeles award for 
achievement in medicine and alco- 
hol rehabilitation . . . LCDR James 
T. Dalton (MSC), first naval officer 
selected to serve as executive as- 
sistant to Dr. Robert N. Smith, As- 
sistant Secretary of Defense (Health 
Affairs) . . . LT Warren Williams, 
Jr. (MSC), elected president of the 
Washington, D.C. chapter of the 
National Naval Officer Association. 
This association is dedicated to the 
promotion of human rights and 
racial equality in the naval service. 

Volume 68, September 1977 



War on Shipboard Roaches 

LCDR Robert V. Peterson, MSC, USN 

Cockroaches on ships are as com- 
mon a sight to preventive medicine 
personnel as children with throat 
inflammations are to pediatricians. 
In 1975, Navy preventive medicine 
personnel reported that of 644 ships 
they visited, 44% were infested 
with cockroaches. Navy medical 
entomologists examined the reasons 
for this high infestation rate at the 
Triennial Environmental Workshop 
for Military Entomologists held 10- 
14 January 1977 at Fort Sam Hous- 
ton, Tex. Major factors contributing 
to cockroach infestation were re- 
ported to be: 

• shipboard structural deficiencies 
which provide places where cock- 
roaches can hide. 

• optimal environmental conditions 
(temperature, humidity, food) for 
cockroach development in food ser- 
vice areas. 

• reinfestation when infested sup- 
plies are used to replenish ships 
previously freed of roaches. 

• poor execution of cockroach con- 
trol programs, usually due to lack 
of interest, motivation and training 
on the part of the ship's crew, as 
well as poor techniques and inade- 
quate pesticide supplies. 

A more unusual reason for infes- 
tation is roach resistance to the 
chemicals used to kill them. 

Closed environment. The ideal 
cockroach habitat requires harbor- 
age, food, moisture, and warm 
temperatures. The closed environ- 
ment aboard ship, especially in gal- 
leys, supplies these needs in abun- 
dance. Galleys are usually well in- 
sulated and have built-in roach har- 

LCDR Peterson is officer in charge of the 
Navy Disease Vector Ecology and Control 
Center, Alameda, Calif. 94501. 

borages such as false bulkheads and 
overheads, large overhead clusters 
of wiring, cracks between stainless 
steel flashing, ill-fitting or torn 
lagging, and many inaccessible 
cracks and crevices which provide 
thousands of hiding places for 
roaches. Galleys may be used 
throughout the day, from early 
breakfast to midnight rations. When 
food service workers are constantly 
busy, they have little time to clean 
the galley; the resulting accumula- 
tions of grease and food particles 
are a continuous source of food for 
roaches. Ovens, steam tables, ket- 
tles, and dishwashers contribute to 
warm temperatures and high hu- 
midity (moisture) in the galley, 
completing the habitat require- 
ments for cockroaches. 

When these ideal environmental 
conditions exist, as they do on most 
ships, more roaches survive for 
longer periods of time and larger 
broods are hatched more often. If 
we consider all the features of ships 
which contribute to large roach 
populations, it becomes clear why 
cockroaches have little difficulty 
establishing themselves aboard 
ships and multiplying rapidly. 

How, then, can this problem be 
attacked and the commensal rela- 
tionship between cockroaches and 
sailors aboard ship broken? On 
Navy ships, the solution has usually 
been to modify chemical control 
procedures by increasing the dos- 
age of insecticide, treating areas 
more frequently, or changing the 
insecticide. But these methods have 
not significantly reduced cockroach 
infestation on ships; in fact, they 
may have contributed to greater re- 
sistance of shipboard roaches to 

Food supplies coming on board ship are 
treated for hidden cockroaches 

Shipboard galleys provide thousands of 
hiding places where roaches can breed 

Spraying insecticides helps prevent the 
spread of cockroaches aboard ship 


U.S. Navy Medicine 

The solutions to the problem are 
neither simple nor cheap. Radical 
modifications of galleys will be re- 
quired. The plethora of cockroach 
hiding places must be eliminated by 
analyzing the physical characteris- 
tics of ships and designing modifi- 
cations for problem areas. Such 
designs should be used in con- 
structing new ships to avoid build- 
ing roach harborages into the ship. 
Galley temperature and humidity 
must be lowered to reduce roach 
population densities. Good sanita- 
tion practices must be followed 
scrupulously. Most important, the 
command and its responsible medi- 


Cockroaches thrive on dirty plates 
stacked in ship's galley 

cal personnel must be committed to 
conducting an effective control pro- 

Further research will also help 
solve the problem. We need to 
study ways to protect roach-free 
ships from reinfestation with in- 
fested food products. Research is 
needed to screen and select the best 
pesticides for shipboard use and to 
evaluate the practicality of recent 
advances in pesticide application 
techniques and equipment designed 
for cockroach control. Training rele- 
vant to the needs of each command 
must be provided. 

The Bureau of Medicine and Sur- 
gery is taking initiatives in all these 
areas. But before real progress can 
be made in ridding ships of cock- 
roaches, we need a commitment of 
funds to support research, together 
with a commitment of support from 
each command, each Navy ento- 
mologist, and all personnel involved 
in shipboard cockroach control. 

teriophage typing is an epidemiologic 
tool. Submission of specimens for typ- 
ing is indicated when several Staphy- 
lococcus aureus cultures are suspected 
of having a common origin, such as in 
outbreaks of infection in hospitals. The 
technique is also useful in determining 
the source of intoxications in foodborne 
outbreaks of disease caused by staphy- 

Bacteriophage typing of S. aureus is 
available from Navy Environmental and 
Preventive Medicine Unit No. 2, Nor- 
folk, Va. Pure cultures of S. aureus are 
accepted from all Navy medical facili- 
ties. Specimens should be submitted on 
agar slants labeled with appropriate pa- 
tient identification information and 
specimen source. 

LEAVE/TRAVEL TIME . . . Current 
regulations state that leave, proceed 
time, and travel time are charged in that 
order, with travel time counted in whole 
days. At the Officer Indoctrination 
School at Newport, Medical Department 
officers are told they have until 2400 of 
their last travel day to report to their 
new duty station. To require officers to 
report earlier is to deprive them of 
travel time to which they are entitled. 

AUDIT TIPS . . . Commands should en- 
sure that personnel who distribute pay 
checks do not participate in the prepara- 
tion of time or leave records (see NAV- 
COMPT Manual, par. 045012-2C[1]). 
Also, commands should ensure that re- 
quests for overtime or compensatory 
time are approved in writing before the 
work is performed, as required by SEC- 
NAV Instruction 7000. 11 A. 

MILITARY DOs ... A divisional society 
of osteopathic physicians serving in the 
U.S. Armed Forces and Public Health 
Service has been approved by the 
American Osteopathic Association. For- 
mation of the new Association of Mili- 
tary Osteopathic Physicians and Sur- 
geons will enable AOA members serv- 
ing in the military to seat representa- 
tives in the AOA House of Delegates for 
the first time next summer. Military 
osteopathic physicians were previously 
eligible for AOA membership but had 
no separate organization to represent 

President of the new Association of 

Military Osteopathic Physicians and 
Surgeons is CDR Robert D. Lutz, MC, 
USNR, a doctor of osteopathy. 

Approximately 500 osteopathic physi- 
cians serve in the Armed Forces and 
Public Health Service, many in intern 
and residency training programs. 

The next business session of the As- 
sociation of Military Osteopathic Physi- 
cians and Surgeons will be held in 
Atlanta in November 1977, in conjunc- 
tion with the Annual AOA Scientific 
Seminar and Convention. 

Membership in the new Association 
is open to members of the Reserve. 


audiometer isn't working, a simple 
plug-in part or adjustment may be all 
that's needed. Call the Naval Aerospace 
Medical Institute (NAM1) Hearing Con- 
servation Service — (Area code 904) 452- 
4457, Autovon 922-4457 — for advice, or 
to order replacement parts. For difficult 
repairs and annual calibrations, pack 
audiometers in tri-wall cardboard car- 
tons, with at least one inch of absorbent 
material on all sides, and ship to: Naval 
Aerospace Medical Institute, Hearing 
Conservation Service (Code 11), Naval 
Air Station, Pensacola, Fla. 32508. 

When audiometers are sent to NAMI, 
accessories such as headphones, hand 
switches, bone vibrators, and cords 
should also be forwarded. Not to be sent 
without NAMI approval are mounting 
racks, tape recorders, phono decks, 
operation manuals, and special test 

MORE HEARING VANS . . . Encour- 
aged by the success of an experimental 
mobile hearing conservation unit at 
NRMC Charleston, the Medical Depart- 
ment is now procuring four more 
hearing conservation vans for use by 
naval regional medical centers and hos- 
pitals. In the Charleston pilot project, a 
van brought Navy audiometric techni- 
cians to local shore facilities and ships 
in port, where they tested Navy mem- 
bers' hearing and provided ear protec- 
tors. The Charleston van, which reached 
many people whose hearing had never 
been tested, demonstrated the feasibil- 
ity of such a system of delivering audi- 
ometry. The project also helped reduce 
the amount of work time that is lost 
when Navy members must travel to a 
clinic for hearing tests. 

Volume 68, September 1977 


As pari of Solid Shield 77, medical officers care for simulated casualties aboard USS Coronado 

On Duty 

Solid Shield 

The more you sweat in peace, 
the less you bleed in war. 

Chinese proverb 

There was plenty of "sweating in 
peace" going on during Operation 
Solid Shield 77, held last May in the 
southeastern United States. 

Solid Shield 77 was the tenth in a 
series of annual joint exercises in- 
volving the U.S. Navy Atlantic 
Fleet, Fleet Marine Force Atlantic, 
U.S. Army Force Command, and 
U.S. Air Force Military Airlift and 
Tactical Air Commands. In this 
massive exercise, with some 40,000 
officers and men, and more than 20 
ships participating, emphasis was 
on command control in a unified 



Advance Force nagship for the 
amphibious assault was USS Coro- 
nado (LPD-1 1 ). The helicopter capa- 
bility of the amphibious assault 
ship, the landing craft and amphib- 
ious capability of the amphibious 
transport dock, and the troop-carry- 
ing capability of the amphibious 
transport were integrated for lifting 
U.S. Marines to the assault area 
and delivering them to the beach. 

A highlight of the Solid Shield 77 
exercise was Coronado's recovery of 
more than a dozen "survivors" who 
appeared when the scenario called 
for the minesweeper USS Illusive to 
be "sunk" by an enemy mine. 
Members of Coronado's medical 

department sprang into action as 
survivors were received over the 

Directing all medical activities 
was LCDR Lee C. Krapin (MC), a 
neurologist from Naval Regional 
Medical Center Philadelphia. "The 
drill was made realistic by the skill- 
ful acting of the men assigned the 
role of patients," Dr. Krapin re- 
members. "I recommend that in 
future exercises the medical prob- 
lems include mock physical findings 
and X-rays to heighten the realism 
of the situation." 

LCDR Krapin screened each pa- 
tient for injuries and established 
treatment priorities. He consulted 
often with LT Paul F. Getty (DC), 

U.S. Navy Medicine 

Helicopters sweep the landing zone clear of mines 

Volume 68, September 1977 

A reconnaissance team rides the waves 
during evening exercises 


Joint Control Group meets to evaluate day's exercise 

assigned to Coronado on temporary 
active duty while the ship's regular 
dental officer attended school. 

"The simulated casualty exer- 
cises allowed dental department 
members to work hand-in-hand with 
the medical department in an emer- 
gency," Dr. Getty says. "We all 
found that it was essential for us to 
be completely familiar with the 
medical supplies aboard— where to 
find them, and how to use them." 

Can't wait. The spiritual needs of 
crewmembers were the province of 
LCDR Richard Lafer, a Naval Re- 
serve chaplain from Minneapolis. 
He, too, stresses the importance of 
early preparation. 

"You can't wait to get your train- 
ing after the battle begins," Chap- 
lain Lafer says. "Even though we 
knew this was only a simulated 
exercise, it was still shocking to 
come out on deck and see a dozen 
men lying there crying out for a 
doctor, a corpsman, or a chaplain. 
There was no time then to ask for 
directions. We just got busy." 

Representatives of the Joint Con- 
trol Group and the various units in- 
volved in Solid Shield 77 planned, 
directed, and evaluated the exer- 
cise. The group met each evening to 
discuss the day's activity and plan 
for the next test of Coronado's read- 

While some men were busy with 
rescue missions, other Solid Shield 
participants were kept hopping— 

LCDR Krapin and LT Getty confer about patient care 


Chaplain Lafer attends the spiritual needs of an "Injured" man 

and sometimes bobbing— else- 
where. A Marine Corps Force Re- 
connaissance team rode the waves 
in a rubber Zebra boat inserted into 
the exercise secretly at sunset from 
Coronado's well deck. Mine coun- 
termeasures Squadron 12 kept the 
landing zone clear of mines at night 
by minesweeping vessels and dur- 
ing the day by helicopter. And day 
in, day out, small boats were 
launched from Coronado to carry 
out the many tasks required of the 
Advance Force. 

Realistic exercises like Solid 
Shield 77 ensure the U.S. Navy will 
be ready to meet the nation's needs 
for quick, decisive response at sea. 

—Story and photos by CDR David L. 
Woods, USNR 

LCDR Krapin screens patient for in- 
juries to determine treatment priorities 


Instructions and 


Dispensing over-the-counter drugs 

Navy health care facilities may establish programs 
for handing out over-the-counter drugs, provided the 
medications and quantities to be dispensed are strictly 
controlled. Medications must be inexpensive, nonhaz- 
ardous drugs used to treat simple conditions such as 
headaches, mild indigestion, mild dermatitis, and com- 
mon colds. Quantities shall be limited to one complete 
regimen or a few days' supply. Medications must be 
dispensed with printed instructions regarding contra- 
indications and when to seek further care. Records shall 
be kept of drugs dispensed in handout programs. — 
BUMED Instruction 6710.61 of 27 April 1977. 

Reporting civilian employment 

The report of civilian positions (MED 5320-3), which 
all Navy medical facilities must submit annually, has 
been revised. The report should show only full-time, 
permanent civilian positions, including executive level, 
general schedule (GS), and ungraded (Wage Board) 
positions, as well as total permanent civilian em- 
ployees. Positions in special employment programs 
should be excluded. Ungraded positions paid at a rate 
equal to GS-16 or above need no longer be listed sepa- 
rately, but should be included in the total number of 
ungraded positions. Positions abolished in the report- 
ing year need no longer be listed. The due date for the 
report has been changed from 1 August to 1 November. 
—BUMED Instruction 5320.2E of 12 May 1977. 

Accreditation of naval hospitals and 
medical centers 

Virtually all naval hospitals and medical centers 
should be able to adhere to standards set by the Joint 
Commission on Accreditation of Hospitals (JCAH), and 
should achieve and maintain JCAH accreditation. But 
because of financial constraints, reaching this goal will 
in many instances require determined and cooperative 

During scheduled visits, the Medical and Dental In- 
spectors General will evaluate action taken to comply 
with JCAH standards. Also, the Bureau will monitor 
the accreditation program closely to ensure that the 
highest quality of health care is maintained. 

The BUMED Health Care Administration Division 
(Code 72) is the contact point for matters pertaining to 
the JCAH accreditation program. 

Volume 68, September 1977 

The costs of the JCAH survey program are funded by 
the Bureau. Activities to be surveyed may order sup- 
plies or services locally, using accounting data provided 
by BUMED Code 462. Federal hospitals are not re- 
quired to pay the nonrefundable JCAH survey deposit 
when they submit an application for survey. 

Naval hospitals and medical centers may request a 
survey following procedures set forth in this instruc- 
tion. BUMED Code 72 should be informed as soon as 
the scheduled survey date is known. 

Naval hospitals and medical centers shall take im- 
mediate action to correct any deficiencies identified in a 
JCAH survey report. A status report of such actions 
shall be sent to BUMED Code 72 within 90 days after 
the facility receives the survey results. — BUMED In- 
struction 6000. 2B of 20 May 1977. 

Disaster drills 

In line with requirements of the Joint Commission on 
Accreditation of Hospitals, naval regional medical 
centers and hospitals shall hold at least one drill every 
six months to practice their plan for handling external 
disasters; a separate drill must be held for each work 
shift. Practice drills for dealing with internal disasters 
shall be held three times each quarter. 

A semiannual letter report (MED-3440-2) shall be 
sent to BUMED (Code 72) describing drills held in the 
previous six months. Reports are due on 15 May and 15 
November. A complete file documenting performance 
of drills shall be maintained for JCAH review. — BU- 
MED Instruction 3440.7 of 17 May 1977. 

Transferring medical treatment records 

This change to BUMED Instruction 6150. ID sets 
forth specific procedures for forwarding medical 
records and X-rays when patients are referred to other 
military health care facilities for consultation or spe- 
cialty treatment. Reports of clinical services provided 
by the consulting facility must be forwarded promptly. 
Records should be returned to the patient's medical 
facility immediately after the consultation or procedure 
for which the patient was referred.— BUMED Instruc- 
tion 6150.1D, change transmittal 1, of 6 June 1977. 

Disposing of Marine Corps health 
and dental records 

The health and dental records of Marine Corps mem- 
bers separated for any reason will be closed on the date 
of separation. The records will be delivered to the com- 
mand that maintains the enlisted member's Service 
Record Books or the officer's Officer Qualification 
Records. These health and dental records will remain 
with the member's personnel records until they are re- 
tired to the National Personnel Records Center in St. 
Louis. These new procedures were included in change 
91 to the Manual of the Medical Department, issued 19 
May 1977.— BUMED Notice 6150 of 15 June 1977. 


Notes & Announcements 


CAPT Bennett F. Avery, MC, USN (Ret,), former 
editor of the Armed Forces Medical Journal, died on 2 
July 1977 in Copenhagen, Denmark, at age 75. 

Born in Vassar, Mich., on 21 Sept 1901, CAPT Avery 
received his bachelor of arts degree in 1923 from the 
University of Michigan, where he also received his 
M.D. in 1925 and a master's degree in science in 1926. 
He was a Rockefeller Fellow at the University of Michi- 
gan in 1926 and at the University of Chicago Graduate 
School from 1928 to 1930. 

Before entering the naval service, CAPT Avery was 
professor of anatomy at the American University Medi- 
cal School in Beirut, Lebanon; dean of the Boston Uni- 
versity School of Medicine; and advisor to the Imperial 
Iranian Ministry of Health. 

Dr. Avery was commissioned a captain in the Medi- 
cal Corps, U.S. Navy on 6 Jan 1950. He reported to the 
Bureau of Medicine and Surgery in January 1952 as 
director of the publications division, and in July 1955 
became director of the Armed Forces Medical Publica- 
tion Agency and editor of the Armed Forces Medical 
Journal. He later served as national coordinator of 
medical education for the National Defense Program 
from 1958 to 1966, when he retired. 

Dr. Avery was a member of the American Medical 
Association, Association of Military Surgeons of the 
United States, Massachusetts Medical Society, Norfolk 
County Medical Society, American Public Health Asso- 
ciation, Royal Society of Health, Society of Experi- 
mental Biology and Medicine, New York Academy of 
Sciences, U.S. Naval Institute, and the American Asso- 
ciation for the Advancement of Science. 


Congratulations to Medical Department officers 
recently recommended for promotion to captain: 

Medical Corps: CDRs Robert R. Abbe, Billy J. Blankenship, 
Robert H. Cave, Daniel H. Day, Valentine D. Galasyn, Joseph 
Honigman, Raymond B. Johnson, Burton O. Leeb, Glen D. 
McKnight, Jr., James W. Reid, Jr., Sandro R. Sandri, and 
Lloyd W. Stetzer. 

Dental Corps: CDRs Don M. Barron, Barry Benn, Carmen 
A. Ciardello, Leonard F. Hodes, Thomas L. Hurst, Charles 
M. Johnson, Jack V. Lowman, Clyde L. Sabala, Thomas N. 
Salmon, and Robert G. Schonbrun. 

Medical Service Corps: CDRs Ann C. Hatten, Sammy W. 
Joseph, Paul D. Nelson, Jack J. Palmer, and Donald E. 

Nurse Corps: CDRs Louise J. Adams, Joan C. Bynum, Eva 

F. Carson, Marie A. Chisholm, Margaret C. Damiani, Lucille 

G. Emond, Alma M. Gomes, Mary F. Hall, Dorothy M. 
Jacobson, Mary Kelly, Eleanor J. Miller, Jo Ann Morton, 
Lois E. Nickerson, Frances A. Noble, Irene M. Stuart, and 
Dorothy A. Yelle. 



The following dental continuing education courses 
will be offered in December 1977: 

National Naval Dental Center, Bethesda, Md. 

Endodontics 5-7 Dec 1977 

Eleventh Naval District, San Diego, Calif. 

5-7 Dec 1977 

U.S. Army Institute of Dental Research, Walter Reed 
Army Medical Center, Washington, D.C. 

Endodontics 5-8 Dec 1977 

Letterman Army Medical Center, San Francisco, Calif. 
Current concepts of 
restorative dentistry 5-8 Dec 1977 

Requests for courses administered by the Comman- 
dant, Eleventh Naval District, should be submitted to: 
Commandant, Eleventh Naval District (Code 37), San 
Diego, Calif. 92132. Applications for other dental con- 
tinuing education courses should be submitted to: Com- 
manding Officer, Naval Health Sciences Education and 
Training Command (Code 5), National Naval Medical 
Center, Bethesda, Md. 20014. Applications should 
arrive six weeks before the course begins. 

Cross-country travel and travel from outside the con- 
tinental U.S. to attend dental continuing education 
courses generally will not be approved due to funding 


The Armed Forces Institute of Pathology (AFIP), 
Washington, D.C, has announced these training ses- 

• The 14th annual forensic dentistry course to be held 
3-6 Oct 1977. Subjects to be covered include recent ad- 
vances in identification, dental identification in mass 
disasters, bite marks, and the relationship between 
forensic dentistry and the work of the Federal Bureau of 
Investigation. There will be laboratory sessions and a 
panel discussion on identifying human remains by 
comparing dental records. 

• The 1977 AFIP legal medicine symposium will be 
held 13-15 Oct 1977. The symposium is designed for 
people in law, medicine, dentistry, hospital administra- 
tion, and nursing. Attendees should be well versed in 
the principles of law or medicine, have five or more 
years working experience and three or more years in an 
executive or decision-making capacity in law or medi- 
cine. Registration is limited to federal government 

U.S. Navy Medicine 

• A gynecologic pathology course covering basic 
anatomy and gross and microscopic pathology of the 
female reproductive tract, offered 1-4 Nov 1977. Prior- 
ity is given to military applicants preparing for specialty 
boards in obstetrics and gynecology. 

• An otolaryngic course covering temporal bone pa- 
thology and surgical pathology of the head and, neck. 
Requirements for admission are flexible but preference 
is given to residents and practitioners in otolaryngology 
and pathology who want to learn more about ear, nose 
and throat pathology. The course is free and will be 
given quarterly starting each January, April, July, and 
October. Physicians seeking shorter training periods 
will be considered. 

Applications for these courses should be submitted to 
the Director, Armed Forces Institute of Pathology, At- 
tention: AFIP-EDZ, Washington, D.C. 20306. 


"The Federal Health Services in the Next Decade" is 
the theme of the 84th annual meeting of the Association 
of Military Surgeons of the United States (AMSUS), to 
be held 27 Nov-1 Dec 1977 at the Shoreham Americana 
Hotel, Washington, D.C. 

Dr. Theodore Cooper, former Assistant Secretary of 
Health, Department of Health, Education, and Wel- 
fare, will analyze the Federal Government's recent 
swine flu program. More than 75 papers will be pre- 
sented, and a large selection of professional exhibits 
will supplement the scientific sessions. A film program 
is also scheduled. 

General chairman for the meeting is James H. Erick- 
son, M.D., director of the Bureau of Medical Services, 
Health Services Administration, U.S. Public Health 
Service. Faye G. Abdellah, Ph.D., chief nurse officer, 
Public Health Service, and director, Office of Long 
Term Care, Health Care Financing Administration, 
DHEW, is program chairman. James D. Felsen, M.D., 
staff director, Office of the Surgeon General, Public 
Health Service, is program vice chairman. 

For further information write: AMSUS, 10605 Con- 
cord St., Suite 306, Kensington, Md. 20795. 


The Uniformed Services University of the Health 
Sciences (USUHS) is accepting applications for admis- 
sion to its class of 1982. 

Interested persons must apply through the American 
Medical College Application Service, 1776 Massachu- 
setts Ave., Suite 301, Washington, D.C. 20036. Appli- 
cants should submit all required materials well in ad- 
vance of the 15 Nov 1977 deadline. 

New medical college admission test scores are re- 
quired from all applicants. MCAT scores from before 
1977 will not meet this requirement. Individuals who 
did not take the new medical college admission test in 
the spring must arrange to do so this fall to be con- 

sidered for the 1982 class. 

For more information write to: Admissions Office, 
Uniformed Services University of the Health Sciences, 
4302 Jones Bridge Rd., Bethesda, Md. 20014. 


The Wilford Hall USAF Medical Center, San Anto- 
nio, Tex., will host the 13th annual uniformed services 
pediatric seminar to be held 13-16 March 1978 at the 
Marines Memorial Club, San Francisco, Calif. 

Abstracts are sought for consideration of the Bruton 
Award, presented for the best research paper, and the 
Margileth Award, presented for the best clinical paper. 
Selections for both awards will be made from completed 
papers, which will be requested after the abstracts are 

Abstracts should be at least 300 words. Authors 
should indicate on the abstract whether the article is 
considered research or clinically oriented. Submit ab- 
stracts by 15 Nov 1977 to: COL Howard H. Johnson, 
Wilford Hall USAF Medical Center (SGHP/25), 
Lackland AFB, Tex. 78236. 


Thirty-nine Medical Service Corps officers and one 
Coast Guard officer graduated from the Naval School of 
Health Care Administration on 16 June 1977. CAPT 
E.M. Bryant, Jr. (MSC), commanding officer at 
NSHCA, presided at the ceremony which marked the 
38th consecutive year of the health care administration 
program and fifth year of direct affiliation with The 
George Washington University Department of Health 
Care Administration. 

The Surgeon General's Award for Scholastic Achieve- 
ment went to LTJG Brian Colfack (MSC), who com- 
pleted the program with a 4.0 cumulative average. LT 
Charles J. Rosciam (MSC) was cited for outstanding 
military leadership. 

The graduates are: J. Anderson, R,W. Boyles, G.R 
Brown, R.E. Bubb, B.G. Clark, B.R. Colfack, CD. Quit, J.B. 
Dillard, F.J. Dunaway, B.R. Edgmon, K.W. Franklin, G.D. 
Fudge, J.N. Gallis, S.E. Garnto, J.M. Garrett, J.A. George, 
J.E. Greenan, D.A. Hargett, G.S. Haslam, R.H. Hazelton, 
D.L. Holm, P. Horwhat, S.M. Hynes, R.A. Kulcsar, W.F. 
Lorenzen, R.C. Marthouse, D.H. McGarvey, C.F. McGinn, 
S.D. Olson, R. Otlowski, R.L. Patton, J.C. Peterson, P.M. 
Peterson, R.W. Rodell, C.J. Rosciam, R.M. Schnable, C.T. 
Shehane, J.E. Shore, C.A, Spencer, R.T. Williams. 


Navy personnel have been asked to display the 
familiar "Go Navy" bumper stickers, which are avail- 
able from LTJG Sandy Geiselman, Navy Recruiting 
Command (Code 45), 4015 Wilson Blvd., Arlington, Va. 
22203. Her telephone number is (202) 692-4726 or Auto- 
von 222-4726. 

Volume 68, September 1977 


A Questionnaire for Preventive Dentistry 

CDR L.W. Blank, DC, USN 

Teaching has long been recognized as an impor- 
tant technique for helping dental patients establish 
effective oral hygiene habits (1,2,3). A means of 
obtaining feedback from our patients is invaluable in 
assessing the effectiveness of our teaching methods. 
This article will present an evaluation mechanism (a 
questionnaire) and describe a survey conducted 
aboard the USS Nimitz to find out whether crew- 
members were benefitting from preventive dentistry 

The Nimitz preventive dentistry program, estab- 
lished about three years ago, consists of an oral 
prophylaxis, scaling of the teeth, and stannous fluo- 
ride application. Lectures, television presentations 
and a dental disease prevention class are also of- 
fered. The one-hour class, taught by a dental techni- 
cian, is given to six crewmembers at a time. In the 
first part of the class, students learn the causes of 
dental caries and periodontal disease, with emphasis 
on the role of bacterial plaque in tooth decay. To in- 
dividualize instruction, illustrations are redrawn on a 
chalkboard for each class, and a phase contrast 
microscope coupled to a television system is used to 
show students their own plaque samples. The second 
part of the class is devoted to group and individual 
instruction in how to use disclosing media, dental 
floss, and intrasulcular toothbrushing techniques. 


According to Cassidy [4], people establish new 
habits by progressing through five stages: aware- 
ness, interest, involvement, action, and habit. To 

CDR Blank, formerly a 8taff member of the Dental Depart- 
ment, USS Nimitz, is in graduate training at the University of 
Michigan School of Dentistry, Ann Arbor, Mich. 48109. The 
author thanks CAPT Ellsworth H. Plump (DC| for assistance and 
support and DT2's S.I. Bruce, R.L. Holmes, and R.A. Jamison 
for their help in running the Nimitz Preventive Dentistry Pro- 


find out how well we were helping patients achieve 
the first stage— awareness of preventive techniques 
—and how we could improve our teaching methods, 
the Nimitz preventive dentistry staff developed a 
questionnaire for patients. Each question covers 
material discussed in the dental disease prevention 
class. We distributed the questionnaire to 123 crew- 
members, of whom 65 had attended the class and 54 
had not. To ensure a random sampling, every fifth 
person who reported to the dental clinic was given a 
questionnaire. Since a computerized recall system 
involving all crewmembers is used to set up dental 
appointments on the ship, a certain number of non- 
voluntary patients (with assumed low dental inter- 
est) reported to the clinic and were included in the 
study, giving us a good cross section of people. One 
form was not returned, and three forms which were 
returned incomplete were not included in our 
analysis; thus, 119 men comprised the final sample. 
All questionnaires were graded by the same 
person, who used an answer key to ensure that re- 
sponses were judged by the same standard. To elim- 
inate bias in scoring, the grader did not know which 
questionnaires were filled out by men who had at- 
tended the class. 


The mean number of correct answers, with stand- 
ard deviation, was 7.5 + 1.6 for the 65 crewmembers 
who had attended the dental disease prevention 
course, and 5.5 + 1.4 for the 54 men who had not. 
Thus we found that class "graduates" scored higher 
on the questionnaire than did crewmembers who had 
had no preventive dentistry training in the Nimitz. 

In question 4, the men were asked how many 
times a week they use dental floss. The mean num- 
ber of times per week and standard deviation was 
4.7 + 2.4 for the 65 men who had attended the class, 
and 2.7 + 2.3 for the 54 men who had not attended 
the class— a notable difference. 

U.S. Navy Medicine 


INTRODUCTION: this questionnaire is not a test; your answers will tell us if we are 






1, 2, 3, 4, 5, 6, 7 


LESS THAN 1, 1, 2, 3, 4, 5, 6, 7, MORE THAN 7 





TOOTH Ujr* \ 







Volume 68 , September 1977 2 7 





























2g U.S. Navy Medicine 

We analyzed the frequency of incorrect answers 
for crewmembers who had attended the class, and 
ranked the questions in order of how often they were 
answered incorrectly. The question answered incor- 
rectly most often was 6A— When brushing, where do 
you place the tips of the bristles when you begin each 
stroke?— followed by: 

3. How many times per day must you thoroughly 
clean your teeth, with the toothbrush and dental 
floss, to prevent gum disease, tooth decay and bad 

6C. Is this brush stroke large and fast? small and 
slow? large and slow? small and fast? 

6B. What kind of toothbrush stroke do you use 
when brushing the sides of your teeth? 

5A. When using dental floss to clean between 
your teeth, how do you hold the floss between your 

1. What is the single most important agent which 
causes tooth decay, gum disease, and bad breath? 

2. If tooth decay and gum disease are not con- 
trolled, what will eventually happen to the teeth? 

7. Name the kind of toothpaste you use. 

5B. How do you move the dental floss once you 
get it between your teeth? 

Question 8— Who is the one person responsible for 
maintaining your teeth in good health?— was the 
question most often answered correctly. The fact 
that most men surveyed answered it correctly indi- 
cates that our patients understand they are responsi- 
ble for their own dental health. Most of them know 
they should use a fluoride toothpaste (question 7), 
and that dental floss should not be used in a 
"sawing" motion (question 5B). Many patients 

know that bacteria cause most dental diseases 
(question 1), that they will lose their teeth if those 
teeth are neglected (question 2), and that in flossing, 
the dental floss should be wrapped around each 
tooth (question 5A); however, these points needed 
some reinforcement. The concept that required the 
most reemphasis was daily use of intrasulcular 
brushing— using a slow, small motion to clean the 
teeth (questions 6A, 3, 6C, 6B). We told our staff 
members which material students did not seem to 
remember and asked staff members to reemphasize 
these points in class and during dental appoint- 

We made no attempt to ascertain when the person 
answering the survey had last attended the class, or 
whether the time that had elapsed made any differ- 
ence in how much information he remembered. (This 
area offers an opportunity for further study.) 
However, we did find out that crewmembers who 
had taken the class scored higher on the question- 
naire and (if we assume responses were honest) use 
dental floss more often than men who had not had 
the training. We discovered that our class is helping 
to achieve the goal of the Nimitz Preventive Den- 
tistry Program: to establish the habit of good oral 


1. Parmly LS: Summum Bonum. London: Burgess and Hill, 

2. Hartzell TB: The patient's needs. J Am Dent Assoc 17: 
1833, Oct 1930. 

3. Barkley RF: Successful Preventive Dental Practices. 
Macomb, 111.: Preventive Dentistry Press, 1972, p 28. 

4. Caasidy R: Psychological factors in preventive dentistry. 
Ala J Med Sci 5(3):357-369, 1968. 



Plaque, germs, bacteria, bacte- 

4. Answers to this question were 

5A. A 

rial acids, bacterial chemicals, 

not included in the overall scor- 

5B A or C 

bacterial wastes. 

ing, because there was no cor- 

uLf, fi KJfl ^/ 

rect answer. Answers were 

6A. D 


Loss of teeth, teeth fail out, 

analyzed separately to compare 

6B. A, C, D, E, or combination 

teeth rot out, teeth removed, 

flossing habits of crewmem- 

of these answers. 

have to wear dentures. 

bers who attended the class 

6C. B 

with flossing habits of those 



who did not attend (see re- 

7. A fluoride toothpaste. 


8. Me, myself, I, patient's name. 

Volume 68, September 1977 



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